PHSO Casework Decisions
3,644 published casework decisions from the Parliamentary and Health Service Ombudsman (Apr 2021–Mar 2026). PHSO selects a subset of completed investigations for public publication — these 3,644 decisions represent approximately 1.1% of the 321,401 total complaints received across the same period. Source: decisions.ombudsman.org.uk.
3,644
Published Decisions
3,105
Health
539
Parliamentary (Govt)
18%
Upheld / Partly Upheld
HM Courts and Tribunals Service (P-005150)
UK Government
Closed After Initial Enquiries
Complaint handling
Courts
Courts
Complaint handling
Mr U complains about HMCTS and its communication and handling of his concerns following him submitting a money claim online.
Black Country Healthcare NHS Foundation Trust (P-005165)
NHS in England
Not Upheld
Referral
Mr C complains about the mental health trust rejecting his referral on three occasions. He says this delayed his diagnosis and treatment resulting in significant distress and worsening symptoms.
East Suffolk and North Essex NHS Foundation Trust (P-005145)
NHS in England
Partly Upheld
Drugs / medication
Treatment
Treatment
Drugs / medication
Treatment
Transfer, discharge and aftercare
Drugs / medication
Treatment
Drugs / medication
Drugs / medication
Miss J complains about the lack of care Mid and South Essex Hospital Services NHS Trust, a hospital in the Baintree area, and
East Suffolk and North Essex NHS Foundation Trust provided her mother between October and December 2023.
Child Maintenance Service (CMS) (P-005154)
UK Government
Closed After Initial Enquiries
Child maintenance
Mr R complains that CMS has provided a consolatory payment which does not reflect the severity, duration and impact of its failings.
Children and Family Court Advisory and Support Service (CAFCASS) (P-005152)
UK Government
Upheld
Courts
Courts
Courts
Miss A complains about Cafcass and a section 7 report which contained unnecessary confidential information and also its adherence to its policies and her reasonable adjustment needs.
Cornwall Partnership NHS Foundation Trust (P-005147)
NHS in England
Closed After Initial Enquiries
Communication
Communication
Drugs / medication
Drugs / medication
Communication
Communication
Mr S complains about aspects of care and treatment provided to his partner at the end of her life.
Cornwall Partnership NHS Foundation Trust (P-005161)
NHS in England
Partly Upheld
Transfer, discharge and aftercare
Diagnosis
Administration
Complaint handling
Ms R complains the Trust failed to provide appropriate care and support to her son in relation to an episode of psychosis he experienced in February 2023. Ms R also complains about how the Trust handled her concerns.
Lincolnshire Community Health Services NHS Trust (P-005151)
NHS in England
Partly Upheld
Treatment
Transfer, discharge and aftercare
Nursing care
Nursing care
Nursing care
Nursing care
Mrs C complains about her father's nursing care and staff failing to observe his deterioration. She adds staff did not escalate his care to an acute care hospital soon enough.
Care Quality Commission (P-005157)
UK Government
Closed After Initial Enquiries
Complaint handling
Complaint handling
Complaint handling
Complaint handling
Complaint handling
Mrs L complains that the Care Quality Commission’s (CQC) investigation into her mother-in-law’s death was inadequate. She is dissatisfied with the length of time it took to conclude the investigation and the lack of an appeal process or way to challenge the decision. She also raises concerns about the CQC’s failure to hold the care home accountable for its Duty of Candour obligations, its delay in visiting the care home until nine months after her mother-in-law’s death, and its absence of representation at the inquest into her mother-in-law’s passing.
HM Courts and Tribunals Service (P-005155)
UK Government
Closed After Initial Enquiries
Courts
Mr A complains that HM Courts and Tribunals Service (HMCTS) failed to submit two claims. He also complains that HMCTS gave inconsistent information about fee remission and did not handle his complaint properly.
East Midlands Ambulance Service NHS Trust (P-005149)
NHS in England
Partly Upheld
Choice and Consent
Tests
Ms A complains about the care her father, Mr A received from East Midlands Ambulance Service NHS trust on 3 August 2022.
A practice in the North East Lincolnshire area (P-005146)
NHS in England
Partly Upheld
Referral
Mr L complains a GP Practice in Lincolnshire did not refer him for microsuction of his ear wax. He had to pay privately for this treatment.
HM Courts and Tribunals Service (P-005153)
UK Government
Closed After Initial Enquiries
Courts
Mr R complains that H M Courts and Tribunals Service (HMCTS) gave him an impossible deadline for submitting documents for court proceedings. He also complains that HMCTS failed to make reasonable adjustments for him as a person with dyslexia, and that it did not handle his complaint correctly.
Sheffield Teaching Hospitals NHS Foundation Trust (P-005148)
NHS in England
Closed After Initial Enquiries
Treatment
Miss T complains the Trust delayed reporting on her father, Mr N’s CT scan in March 2025.
Tameside and Glossop Integrated Care NHS Foundation Trust (P-005166)
NHS in England
Partly Upheld
Nursing care
Ms W complains about the care and treatment of her father whilst in hospital across September to November 2021. She says the lack of care resulted in his death and led to him being in pain and discomfort across his admittance.
University Hospitals of Leicester NHS Trust (P-005164)
NHS in England
Closed After Initial Enquiries
Referral
Referral
Mr A complains the Trust did not complete a pulmonary TB test before it discharged him on 12 September 2024. He also complains the Trust did not refer him to his GP or the community testing team for TB testing before it discharged him on the same date as above.
Bedfordshire Hospitals NHS Foundation Trust (P-005163)
NHS in England
Closed After Initial Enquiries
Communication
Treatment
Drugs / medication
Mr B complains about his son's care and treatment in February 2024 and his interaction with the Trust. He complains the Trust misused its Violence and Aggression Policy against him, put his son's care at risk because he complained and lost his son's emergency-controlled medication for 72 hours.
University Hospital Southampton NHS Foundation Trust (P-005162)
NHS in England
Not Upheld
Surgery
Choice and Consent
Surgery
Surgery
Risk assessment
Mr O complains about the care and treatment concerning a drainage procedure under his armpit in April 2023. He complains he did not consent to surgery and the surgery was not carried out appropriately.
St George's University Hospitals NHS Foundation Trust (P-005160)
NHS in England
Closed After Initial Enquiries
Communication
Mr O complains the Trust did not properly inform him of the risks and severe side effects of a stem cell transplant procedure. He complains this means he was not able to give fully informed consent.
North West Anglia NHS Foundation Trust (P-005156)
NHS in England
Upheld
Diagnosis
Mr R complains the Trust missed opportunities to diagnose his right coronary artery was becoming blocked.
University Hospitals of Liverpool Group (P-005158)
NHS in England
Not Upheld
Diagnosis
Mr N complains that breast care clinicians did not monitor his wife properly for recurrent cancer, and dismissed her concerns, following breast cancer surgery.
University Hospitals Birmingham NHS Foundation Trust (P-005159)
NHS in England
Closed After Initial Enquiries
Drugs / medication
Complaint handling
Communication
Mrs M complains about the care the Trust gave to her late daughter when treating her for Acute Lymphoblastic Leukaemia. She complains about delays in treatment, poor communication, and the complaint handling
An independent provider in the Wealden area (P-005144)
NHS in England
Upheld
Disability
Complaint handling
AI summary: Miss L complained AJM Healthcare took too long to deliver a suitable wheelchair, failed to communicate, and did not collect the old one, impacting her health and finances; also the ICB did not investigate her complaint properly.
Bradford Teaching Hospitals NHS Foundation Trust (P-005140)
NHS in England
Closed After Initial Enquiries
Diagnosis
AI summary: Mrs A complained about delays in diagnosing her skin cancer due to cancelled appointments, leading to distress, discomfort, more complicated surgery, and nerve damage.
King's College Hospital NHS Foundation Trust (P-005139)
NHS in England
Closed After Initial Enquiries
Administration
AI summary: Mrs T complained the Trust lost her two gold rings due to incorrect procedures when recording and handling patient property, causing her stress.
Upheld / Partly Upheld
261 + 403
18% of decisions found fault with the organisation complained about.
Not Upheld
250
Complaint investigated but no fault found. 1 resolved during investigation.
Closed After Initial Enquiries
2,729
PHSO decided not to proceed to full investigation.
Most complained-about:
HM Revenue and Customs (80), University Hospitals Birmingham NHS Foundation Trust (73), NHS England (62), HM Courts and Tribunals Service (51), Manchester University NHS Foundation Trust (50).
Published Decisions Over Time
Excludes 2,729 closed before investigation. Quarterly, by outcome.
Annual Complaints (PHSO-wide)
Official PHSO annual statistics across all organisations
| Year | Received | Investigated | Upheld | Upheld % | Remedy % |
|---|---|---|---|---|---|
| 2019-20 | 54,470 | 12,273 | 1,216 | 9.9% | 0% |
| 2020-21 | 44,127 | 7,822 | 617 | 7.9% | 0% |
| 2021-22 | 62,540 | 13,420 | 727 | 5.4% | 0% |
| 2022-23 | 61,292 | 15,731 | 782 | 5.0% | 0% |
| 2023-24 | 63,462 | 17,320 | 946 | 5.5% | 0% |
| 2024-25 | 35,510 | 10,067 | 519 | 5.2% | 0% |
Remedy % = percentage of PHSO remedies complied with on time
Top Themes
Themes by Upheld Rate
AI-classified themes across PHSO casework decisions
| Theme | Decisions | Upheld | Rate |
|---|---|---|---|
| Delayed Recognition of Deterioration | 747 | 184 | 25% |
| Complaint record keeping failures | 632 | 108 | 17% |
| Clinical negligence harms learning | 460 | 92 | 20% |
| Care plan failures | 436 | 121 | 28% |
| Care and discharge planning | 288 | 77 | 27% |
| No person-centred care | 215 | 46 | 21% |
| Inaccurate and inaccessible patient records | 204 | 37 | 18% |
| Patient dignity and privacy | 147 | 40 | 27% |
| Inadequate Pre-Operative Risk Assessment | 136 | 44 | 32% |
| Duty of Candour implementation | 134 | 43 | 32% |
| Medication Contamination/Misadministration | 128 | 33 | 26% |
| DWP policy impact assessment | 106 | 12 | 11% |
| Poor health and social care integration | 97 | 21 | 22% |
| Mental Health Crisis Referral Delays | 74 | 10 | 14% |
| Coroner family information gaps | 74 | 25 | 34% |
PHSO Complaint Categories
PHSO Categories by Upheld Rate
PHSO's own issue classifications — broad categories such as 'Treatment' cover a wide range of clinical complaints
| Category | Decisions | Upheld | Rate |
|---|---|---|---|
| Treatment | 1,617 | 423 | 26% |
| Diagnosis | 853 | 208 | 24% |
| Communication | 799 | 233 | 29% |
| Complaint handling | 543 | 162 | 30% |
| Drugs / medication | 472 | 135 | 29% |
| Nursing care | 393 | 159 | 40% |
| Access | 363 | 87 | 24% |
| Transfer, discharge and aftercare | 356 | 122 | 34% |
| Referral | 266 | 59 | 22% |
| Administration | 192 | 31 | 16% |
| End of life care | 170 | 50 | 29% |
| Choice and Consent | 167 | 49 | 29% |
| Continuing healthcare | 160 | 14 | 9% |
| Surgery | 148 | 32 | 22% |
| Record keeping and management | 133 | 30 | 23% |
Organisation Accountability
Combines PHSO annual complaint statistics (volume, remedy compliance) with published decisions portal data (uphold rate). Sorted by upheld rate for organisations with 5+ investigated decisions. Benchmark: 73% average upheld rate among fully investigated decisions. This differs from the headline 18% figure, which includes all 3,340 published decisions — most of which were closed before full investigation (upheld/not upheld only applies to fully investigated cases). Sparklines show complaint volumes received 2019–20 → 2024–25.
Received = complaints received in most recent year (PHSO annual data). Remedy compliance = % of PHSO-recommended remedies complied with across all available years. — = no data in that dataset for this organisation.